U.S. Department of State OMB APPROVAL NO.

1405-0015
EXPIRES: 02/29/2012
APPLICATION FOR ESTIMATED BURDEN: 1 HOUR*
(See Page 2)
IMMIGRANT VISA AND
ALIEN REGISTRATION

PART I - BIOGRAPHIC DATA

Instructions: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please
print or type your answers to all questions. Mark questions that are Not Applicable with "N/A". If there is insufficient room on the form, answer on a
separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form.
Warning: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States.
This form (DS-230 Part I) is the first of two parts. This part, together with Form DS-230 Part II, constitutes the complete Application for
Immigrant Visa and Alien Registration.
1. Family Name First Name Middle Name

2. Other Names Used or Aliases (If married woman, give maiden name)

3. Full Name in Native Alphabet (If Roman letters not used)

4. Date of Birth (mm-dd-yyyy) 5. Age 6. Place of Birth (City or town) (Province) (Country)

7. Nationality (If dual national, 8. Gender 9. Marital Status

give both)
Female Single (Never married) Married Widowed Divorced Separated
Male Including my present marriage, I have been married times.
10. Permanent address in the United States where you intend to live, if 11. Address in the United States where you want your Permanent
known (street address including ZIP code). Include the name of a person Resident Card (Green Card) mailed, if different from address in item #10
who currently lives there. (include the name of a person who currently lives there).

Telephone number Telephone number

12. Your Present Occupation 13. Present Address (Street Address) (City or Town) (Province) (Country)

Telephone Number (Home) Office

14. Name of Spouse (Maiden or family name) First Name Middle Name

Date (mm-dd-yyyy) and Place of Birth of Spouse

Address of Spouse (If different from your own) Spouse's Occupation

Date of Marriage (mm-dd-yyyy)

15. Father's Family Name First Name Middle Name

16. Father's Date of Birth Place of Birth Current Address If Deceased, Give Year
(mm-dd-yyyy) of Death

17. Mother's Family Name at Birth First Name Middle Name

18. Mother's Date of Birth Place of Birth Current Address If Deceased, Give Year
(mm-dd-yyyy) of Death

DS-230 Part I This Form May be Obtained Free at Consular Offices of the United States of America
02-2009 Previous Editions Obsolete Page 1 of 4
19. List Names, Dates and Places of Birth, and Addresses of ALL Children.
Name Date (mm-dd-yyyy) Place of Birth Address (If different from your own)

20. List below all places you have lived for at least six months since reaching the age of 16, including places in your country of nationality.
Begin with your present residence.
City or Town Province Country From/To (mm-yyyy) or "Present"

21a. Person(s) named in 14 and 19 who will accompany you to the United States now.

21b. Person(s) named in 14 and 19 who will follow you to the United States at a later date.

22. List below all employment for the last ten years.
Employer Location Job Title From/To (mm-yyyy) or "Present"

In what occupation do you intend to work in the United States?

23. List below all educational institutions attended.

School and Location From/To (mm-yyyy) Course of Study Degree or Diploma

Languages spoken or read:

Professional associations to which you belong:

24. Previous Military Service Yes No

Branch Dates of Service (mm-dd-yyyy)
Rank/Position Military Speciality/Occupation
25. List dates of all previous visits to or residence in the United States. (If never, write "never") Give type of visa status, if known.
Give DHS "A" number if any.
From/To (mm-yyyy) Location Type of Visa "A" Number (If known)

Signature of Applicant Date (mm-dd-yyyy)

Privacy Act and Paperwork Reduction Act Statements

The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide
on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested
information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department
of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the
information to issue you a social security number and card.
*Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering
the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this
collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please
send them to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202

DS-230 Part I Page 2 of 4

 U.S. Department of State
OMB APPROVAL NO. 1405-0015
APPLICATION FOR IMMIGRANT VISA AND EXPIRES: 02/29/2012
ESTIMATED BURDEN: 1 HOUR*
ALIEN REGISTRATION
PART II - SWORN STATEMENT
Instructions: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please
print or type your answers to all questions. Mark questions that are Not Applicable with "N/A". If there is insufficient room on the form, answer on a
separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form. The fee should be paid in United States
dollars or local currency equivalent, or by bank draft.

Warning: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. Even if you
are issued an immigrant visa and are subsequently admitted to the United States, providing false information on this form could be grounds
for your prosecution and/or deportation.

This form (DS-230 Part II), together with Form DS-230 Part I, constitutes the complete Application for Immigrant Visa and Alien Registration.

26. Family Name First Name Middle Name

27. Other Names Used or Aliases (If married woman, give maiden name)

28. Full Name in Native Alphabet (If Roman letters not used)

29. Name and Address of Petitioner Telephone number

30. United States laws governing the issuance of visas require each applicant to state whether or not he or she is a member of any class of
individuals excluded from admission into the United States. The excludable classes are described below in general terms. You should
read carefully the following list and answer Yes or No to each category. The answers you give will assist the consular officer to reach a
decision on your eligibility to receive a visa.
Except as Otherwise Provided by Law, Aliens Within the Following Classifications are Ineligible to Receive a Visa.
Do Any of the Following Classes Apply to You?

a. An alien who has a communicable disease of public health significance; who has failed to present documentation of Yes No
having received vaccinations in accordance with U.S. law; who has or has had a physical or mental disorder that poses
or is likely to pose a threat to the safety or welfare of the alien or others; or who is a drug abuser or addict.
b. An alien convicted of, or who admits having committed, a crime involving moral turpitude or violation of any law Yes No
relating to a controlled substance or who is the spouse, son or daughter of such a trafficker who knowingly has
benefited from the trafficking activities in the past five years; who has been convicted of 2 or more offenses for which
the aggregate sentences were 5 years or more; who is coming to the United States to engage in prostitution or
commercialized vice or who has engaged in prostitution or procuring within the past 10 years; who is or has been an
illicit trafficker in any controlled substance; who has committed a serious criminal offense in the United States and who
has asserted immunity from prosecution; who, while serving as a foreign government official, was responsible for or directly
carried out particularly severe violations of religious freedom; or whom the President has identified as a person who plays a
significant role in a severe form of trafficking in persons, who otherwise has knowingly aided, abetted, assisted or colluded with
such a trafficker in severe forms of trafficking in persons, or who is the spouse, son or daughter of such a trafficker who
knowingly has benefited from the trafficking activities within the past five years.

c. An alien who seeks to enter the United States to engage in espionage, sabotage, export control violations, terrorist Yes No
activities, the overthrow of the Government of the United States or other unlawful activity; who is a member of or
affiliated with the Communist or other totalitarian party; who participated, engaged or ordered genocide, torture, or extrajudicial
killings; or who is a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State.
d. An alien who is likely to become a public charge. Yes No
e. An alien who seeks to enter for the purpose of performing skilled or unskilled labor who has not been certified by the Yes No
Secretary of Labor; who is a graduate of a foreign medical school seeking to perform medical services who has not
passed the NBME exam or its equivalent; or who is a health care worker seeking to perform such work without a
certificate from the CGFNS or from an equivalent approved independent credentialing organization.
f. An alien who failed to attend a hearing on deportation or inadmissibility within the last 5 years; who seeks or has Yes No
sought a visa, entry into the United States, or any immigration benefit by fraud or misrepresentation; who knowingly
assisted any other alien to enter or try to enter the United States in violation of law; who, after November 30, 1996,
attended in student (F) visa status a U.S. public elementary school or who attended a U.S. public secondary school
without reimbursing the school; or who is subject to a civil penalty under INA 274C.
Privacy Act and Paperwork Reduction Act Statements
The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide
on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested
information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department
of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the
information to issue you a social security number and card.
*Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering
the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this
collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please
send them to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202

DS-230 Part II Previous Editions Obsolete

Page 3 of 4
 g. An alien who is permanently ineligible for U.S. citizenship; or who departed the United States to evade military service Yes No
in time of war.
h. An alien who was previously ordered removed within the last 5 years or ordered removed a second time within the last Yes No
20 years; who was previously unlawfully present and ordered removed within the last 10 years or ordered removed a
second time within the last 20 years; who was convicted of an aggravated felony and ordered removed; who was
previously unlawfully present in the United States for more than 180 days but less than one year who voluntarily
departed within the last 3 years; or who was unlawfully present for more than one year or an aggregate of one year
within the last 10 years.
i. An alien who is coming to the United States to practice polygamy; who withholds custody of a U.S. citizen child Yes No
outside the United States from a person granted legal custody by a U.S. court or intentionally assists another person to
do so; who has voted in the United States in violation of any law or regulation; or who renounced U.S. citizenship to
avoid taxation.
j. An alien who is a former exchange visitor who has not fulfilled the 2-year foreign residence requirement. Yes No
k. An alien determined by the Attorney General to have knowingly made a frivolous application for asylum. Yes No
l. An alien who has ordered, carried out or materially assisted in extrajudicial and political killings and other acts of
Yes No
violence against the Haitian people; who has directly or indirectly assisted or supported any of the groups in Colombia
known as FARC, ELN, or AUC; who through abuse of a governmental or political position has converted for personal
gain, confiscated or expropriated property in Cuba, a claim to which is owned by a national of the United States, has
trafficked in such property or has been complicit in such conversion, has committed similar acts in another country, or
is the spouse, minor child or agent of an alien who has committed such acts; who has been directly involved in the
establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or
a man or a woman to undergo sterilization against his or her free choice; or who has disclosed or trafficked in
confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons
Convention or is the spouse, minor child or agent of such a person.
31. Have you ever been charged, arrested or convicted of any offense or crime? (If answer is Yes, please explain) Yes No

32. Have you ever been refused admission to the United States at a port-of-entry? (If answer is Yes, please explain) Yes No

33a. Have you ever applied for a Social Security Number (SSN)? 33b. Consent to Disclosure: I authorize disclosure of information
Yes No from this form to the Department of Homeland Security (DHS), the
Social Security Administration (SSA), such other U.S. Government
Give the number Do you want the Social
Security Administration to agencies as may be required for the purpose of assigning me an SSN
Would you like to receive a replacement assign you a SSN and issue a and issuing me a Social Security card, and I authorize the SSA to share
card? (You must answer YES to question card? (You must answer YES my SSN with the INS.
33b. to receive a card.) to question 33b. to receive a Yes No
number and a card.) The applicant's response does not limit or restrict the Government's
ability to obtain his or her SSN, or other information on this form, for
Yes No Yes No enforcement or other purposes as authorized by law.
34. Were you Assisted in Completing this Application? Yes No
(If answer is Yes, give name and address of person assisting you, indicating whether relative, friend, travel agent, attorney, or other)

DO NOT WRITE BELOW THE FOLLOWING LINE

The consular officer will assist you in answering item 35.
DO NOT SIGN this form until instructed to do so by the consular officer
35. I claim to be:
A Family-Sponsored Immigrant I derive foreign state chargeability Preference
An Employment-Based Immigrant under Sec. 202(b) through my
Numerical limitation
A Diversity Immigrant (foreign state)
A Special Category (Specify)
(Returning resident, Hong Kong, Tibetan, Private Legislation, etc.)
I understand that I am required to surrender my visa to the United States Immigration Officer at the place where I apply to enter the United States, and that the
possession of a visa does not entitle me to enter the United States if at that time I am found to be inadmissible under the immigration laws.
I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to permanent
exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or deportation.
I, the undersigned applicant for a United States immigrant visa, do solemnly swear (or affirm) that all statements which appear in this application, consisting
of Form DS-230 Part I and Part II combined, have been made by me, including the answers to items 1 through 35 inclusive, and that they are true and complete
to the best of my knowledge and belief. I do further swear (or affirm) that, if admitted into the United States, I will not engage in activities which would be
prejudicial to the public interest, or endanger the welfare, safety, or security of the United States; in activities which would be prohibited by the laws of the
United States relating to espionage, sabotage, public disorder, or in other activities subversive to the national security; in any activity a purpose of which is the
opposition to or the control, or overthrow of, the Government of the United States, by force, violence, or other unconstitutional means.
I understand that completion of this form by persons required by law to register with the Selective Service System (males 18 through 25 years of age)
constitutes such registration in accordance with the Military Selective Service Act.

Signature of Applicant

Subscribed and sworn to before me this day of at:

Consular Officer

This Form May be Obtained Free at Consular Offices of

DS-230 Part II The United States of America Page 4 of 4